Routine Splenic Flexure Mobilization Research Articles

Splenic flexure mobilization is an essential role in laparoscopic low anterior resection!

Background: Routine mobilization of splenic flexure whether partial or complete became an essential step in laparoscopic low anterior resections in order to perform an oncologic re­section and to achieve a safe, tension-free anastomosis.Methods: 60 patients with rectal cancer were operated by laparoscopic low anterior resection with high ligation of inferior mesenteric artery in general surgery department, Menoufia university hospital between February 2016 and January 2019. All patients were divided randomly into 2 equal groups based on the techniques used in splenic flexure mobilization whether partial (group A) or complete (group B).Results: The majority of our patients were male 56.6% and 60% in both groups respectively with mean age (54.6±8.8) years in group A and mean age (58.5±9.2) years in group B. The operative time was highly significant lower in group A (269±17.6 minutes) than group B (304±22.4 minutes) while the conversion rate was significantly higher in group B (26.6%) than group A (6.6%). Regarding the postoperative data there was only significantly higher leak from the anastomosis in group A (20%) than group B (3.3%).Conclusions: Complete splenic flexure offer better oncological outcome and low incidence of anastomotic leak but with higher conversion rate, prolonged operative time, more blood loss and more 30 day mortality rate. So it needs more time to gain more experience to overcome these disadvantages.

Examining Utility of Routine Splenic Flexure Mobilization during Colectomy and Impact on Anastomotic Complications

BackgroundDespite a lack of supporting data, routine splenic flexure mobilization (SFM) during colectomy has been thought to reduce anastomotic leak (AL). We evaluated the impact of SFM on outcomes in distal colectomy. Study designThe 2005–2016 NSQIP database identified 66,068 patients undergoing distal colectomy with anastomosis. Cohorts were stratified by addition of SFM. Postoperative outcomes were compared between groups. Regression analysis identified factors affecting odds of developing AL. ResultsSFM was performed in 27,475 patients (41.6%). There was no difference in overall complications between cases with SFM and those without (p = 0.55). SFM had longer operative times (220 min vs. 184 min; p < 0.0001). SFM was not associated with any difference in AL rate (3.6% vs. 3.7%; p = 0.86). Factors most associated with AL were lack of oral antibiotic preparation (OR 1.93; p < 0.001), chemotherapy (OR 1.91; p < 0.001), and weight loss (OR 1.68; p = 0.0005). Operative indication and approach did not affect leak. ConclusionsSFM in distal colectomy increased operative time without decreasing overall complications or AL. Routine splenic flexure mobilization may add risk without significant benefit.

Routine splenic flexure mobilization may increase compliance with pathological quality metrics in patients undergoing low anterior resection.

Mandatory splenic flexure mobilization (SFM) has been debated for rectal cancers. Proponents argue that additional mobilization facilitates a tension-free anastomosis; however, this must be weighed against heightened morbidity. Little is known about the impact of specific techniques on pathology quality metrics. We aim to determine the impact of SFM on pathology quality metrics for patients undergoing rectal resections for colorectal adenocarcinoma. Patients were selected by querying the University of Kansas electronic medical records and the American College of Surgeons National Surgical Quality Improvement Program database based on Current Procedural Terminology codes. Patients were categorized as SFM or non-SFM. Primary outcomes were node yield less than 12 and margin length. There were 146 patients who met the inclusion criteria for chart review and 7369 included from the national database. Splenic flexure mobilization was associated with wider margins (3.52 vs 2.51cm in low anterior resection, P<0.01) and a decreased rate of inadequate nodal staging in patients undergoing low anterior resection (3.7% vs 19.3% P<0.01). SFM may affect surgical quality metrics in patients undergoing resection for distal colon and rectal adenocarcinoma. Further study is warranted to determine whether these differences in quality and pathology translate into differences in oncological outcomes.

Operative technique in robotic left colonic resection.

Minimally invasive techniques have changed the clinical practice in general surgery and provided an improvement of outcomes. Laparoscopic and open surgery have similar oncological outcomes in the colorectal field. Those findings have been proven by prospective randomized multicenter trials and systematic reviews. However, some colorectal operations are still being performed by the open approach. This is partially related to the technical hurdles of the laparoscopic approach (particularly for more complex cases). Robotic surgery can be beneficial in overcoming the laparoscopic hurdles and limitations. Indeed, given the improved dexterity, the 3D stereotactic magnified view (with the camera controlled directly by the surgeon), the tremor filtering technology and the 7 degrees of liberty of the surgical instruments can guarantee a more accurate surgical dissection and tissue manipulation. Herein, after a large robotic experience in this field connected to a robotic program started by Giulianotti et al. in October 2000, we present our approach to robotic left colonic resection with routine splenic flexure mobilization. This approach may be helpful to get more reproducible results, it may be a technical guide and also an additional training tool for surgical residents.

Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results.

To assess the frequency, risk factors and outcomes of iatrogenic spleen injury during minimally invasive colo-rectal surgery with a particular focus on the routine splenic flexure mobilization tehcnique. Exclusion criteria: 1) topic not pertinent to the main topic of the review; 2) all case reports, editorials, conference highlights were excluded. After a title and abstract first selection and a final full-text analysis has been performed. The results of the selected articles are presented. The iatrogenic splenic injury rate during colorectal surgery is 0.96%. The iatrogenic injuries cause around 20% of all splenectomy. Ligaments over-traction is the most frequent mechanism of damage. The routine splenic flexure mobilization is a matter of scientific debate. Risk factors - open surgery, male sex, peripheral vascular disease, malignant neoplasia, diverticulitis, emergency surgery and teaching-hospital status. There is a risk difference according to the procedure: transverse colectomy has the highest risk, followed by left colectomy and total colectomy. The routine mobilization of the left colonic flexure is a debated topic. However, according to some authors (including our experience), this procedure is not a risk factor and it may be advantageous: 1) it does not excessively prolong the total operative time; 2) better surgical skills development; 3) the tension-related ischemia is avoided; 4) wider oncological dissection. Technical accuracy with cautious dissection/visualization can reduce the rate of iatrogenic splenic damage. Laparoscopy decreases the rate of splenic injury by almost 3.5 times. Robotic surgery may have the potential to further reduce this complication, but more data are needed on the topic.

MOBILIZATION OF SPLENIC FLEXURE DURING RECTAL RESECTION

Background. Splenic flexure mobilization (SFM) is a difficult step within both conventional and laparoscopic procedures, often associated with intra- and postoperative morbidity. Additional difficulties occur because of the lack of generally accepted methods for performing SFM. Despite many reports, the routine SFM during low rectal resections remains controversial. Aim. This paper presents the strategy for SFM used in our clinic, as well as the surgical treatment outcomes in patients who underwent low rectal resections with or without SFM. Methods. Two retrospective analyzes of the surgical procedures were made. In the first case, the results of all LS operations with SFM (n=120) were analyzed. In the second case, a retrospective analysis of the LS rectal resections was carried out (low anterior resection (LAR) with the SFM (n=32), pull-through rectal resection with the SFM (n=20) and LAR without SFM (n=94)). Results. In the first analysis, patients were divided into 4 groups: LS-left colectomy, LS-low anterior rectal resection, LS-colproctectomy, and LSpull-through rectal resection. There was no significant difference between the groups in terms of intra- and postoperative complications. In the second analysis, the differences in the operation time, blood loss and hospital stay between low rectal resections were not statistically significant. Anastomotic leakage was detected in 2 patients in the LAR with SFM group, in 8 patients (8.5 %, 8/94) in LAR without SFM group, and in 1 patient in pull-through rectal resection group (5 %, 1/20), p=0.17. Conclusions. Using the laparoscopic approach to SFM, optimal surgical outcomes can be achieved. Routine SFM during low anterior rectal resection is not necessary, because it does not lead to decreased incidence of anastomotic leakage and complications. Routine SFM during pull-through rectal resection is necessary.

Is Routine Splenic Flexure Mobilization Always Mandatory for Left Colectomy? A Comparative Study of 80 Patients with Adenocarcinoma of the Sigmoid Colon

Is Routine Splenic Flexure Mobilization Always Mandatory for Left Colectomy? A Comparative Study of 80 Patients with Adenocarcinoma of the Sigmoid Colon

Laparoscopic Versus Open Resection Without Splenic Flexure Mobilization for the Treatment of Rectum and Sigmoid Cancer

We have hypothesized that splenic flexure mobilization might be selectively undertaken in laparoscopic surgery (LAP) for rectal or sigmoid colon cancer. Oncologic clearance and postoperative morbidity were compared between 119 LAP patients and 145 open surgery (OS), all of whom were treated without splenic flexure mobilization. The operative time was similar in the 2 groups (P>0.05). The complication rate was lower after LAP than after OS (10.0% vs. 25.5%, P=0.043). Anastomotic leakage occurred in 1 patient after LAP. On a median 29-month follow-up, the local recurrence rates did not differ significantly between the 2 groups (0.9% for LAP vs. 2.6% for OS). Laparoscopic procedures without routine splenic flexure mobilization do not increase postoperative morbidity or oncologic risk, as compared with OS. We suggest that laparoscopic rectal and sigmoid cancer resection can be safely conducted with selective splenic flexure mobilization.